Pediatric nursing · practice question
A 2-year-old toddler in the emergency department is being evaluated for dehydration from vomiting and diarrhea. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which action should the nurse take first?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Why
NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
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